7- Shock

Duration and volume of hemorrhage, age and pre-existing cardiovascular fitness of the patient, and the coexistence of massive trauma with multiple direct organ derangement.

Accumulation of lactic acid from anaerobic metabolism and renal failure from prolonged ischemia.

Cellular necrosis, multiple organ failure, and survival is unlikely even with hemodynamic correction.

Respiratory monitoring, cardiovascular monitoring, neurological monitoring, temperature monitoring, urine output monitoring, central venous pressure, echocardiography, and arterial blood gases.

Tumour necrosis factor (TNF), interleukins, platelet activation factor, prostaglandins, and nitric acid.

Weakness and fainting, feeling cold and thirsty, tired appearance, varying mental status, stable pulse and blood pressure with mild blood loss, development of tachycardia with more blood loss, and progressive hypotension with further blood loss.

Inotropes and vasopressors.

To restore tissue perfusion.

Needle decompression and chest tube.

Onset is within minutes and may last weeks.

Angioedema, bronchoconstriction, vasodilatation, hypotension, and urticarial rash.

Hypotension and hypoperfusion complicating severe sepsis.

25 to 90%.

A Foley catheter is introduced to check urine output every hour, with optimum output for adults being 0.5 - 1 ml/Kg/hour.

Tachypnea, air hunger, hypothermia, pale/cold/sweaty skin, slow capillary refill, collapsed veins, and oliguria.

Elevating both legs while maintaining the trunk and the remainder of the patient in the supine position.

The gross reduction of cardiac output.

Cold, sweaty, and inadequate tissue perfusion.

CBC, ABG/lactate, electrolytes, BUN, creatinine, coagulation studies, type and crossmatch, CXR, pelvic x-ray, abdominal US (FAST), abdominal/pelvis CT, chest CT, GI endoscopy, and bronchoscopy.

Tachycardia (HR >120 bpm), tachypnea, hypotension, oliguria, very cool & mottled skin, very anxious, confused.

Administration of oxygen.

Crystalloids (Normal Saline or Lactated Ringer).

Norepinephrine or dopamine to keep a mean blood pressure above 65 mm Hg.

By acute respiratory distress, absent unilateral breath sounds, tracheal shift, and jet black & shift of mediastinum on x-ray.

Hypotension, a normal pulse rate or even bradycardia, and warm dry skin.

Immediate intubation or surgical airway for angioedema and respiratory compromise, fluid resuscitation with IV crystalloid infusion, epinephrine, corticosteroids, and antihistaminic.

Due to developing reservoirs of resistant and virulent organisms, concentration of infected patients in critical care units, more extensive operations in elderly and poor-risk patients, salvage of severely injured patients, and a growing population of immunosuppressed patients.

Trauma, major surgery, gastrointestinal bleeding, retroperitoneal bleeding, ruptured aortic aneurysm, pre- and postpartum hemorrhage, ruptured ectopic pregnancy.

By using a Swan Ganz catheter which is passed into a small branch of the pulmonary artery where it becomes wedged.

Clinical changes in hemodynamic parameters and indices of tissue perfusion.

The sum of the amount in the suction reservoir and the amount mopped up by the swabs, with the latter calculated as the difference in swab weight after and before operation multiplied by a correction factor of 1.5 - 2.

Tachycardia (HR >100 bpm), narrowing pulse pressure, cool clammy skin, mild anxiety.

To maintain a reasonable mean arterial pressure (MAP) to keep the patient alive.

Cardiac muscle contractility, blood volume (preload), and the resistance that the left ventricle needs to overcome to push blood into circulation (afterload).

10%: You donated a unit of blood. Thank you. 20%: You will probably feel a little sick. 40%: You will probably go into hypovolemic shock.

Low blood pressure.

Greater than 92%.

Pericardiocentesis.

Distributive shock.

Third space loss of fluid which further reduces the blood volume.

1 - Initial stage, 2 - Compensatory stage, 3 - Progressive stage, 4 - Refractory stage.

Impaired myocardial contractility, superficial ulcers in the gastrointestinal mucosa, and potential translocation of bacteria and endotoxins.

It can lead to disseminated intravascular coagulation (DIC), depleting coagulation factors and inducing bleeding tendency in the rest of the body.

Class I: <15% of volume loss (750 ml), Class II: 15 - 30% of volume loss (750 - 1500 ml), Class III: 30 - 40% of volume loss (1500 - 2000 ml), Class IV: >40% of volume loss (>2000ml).

Old age, diabetes mellitus, corticosteroids, chemotherapy, malignancy, and HIV/AIDS.

Cardiac output (CO) = stroke volume (SV) x Heart rate (HR).

It leads to alveolar and interstitial edema, reduced compliance and filling of the alveoli with fluid, opening of arteriovenous shunts, and impairment of ventilation, perfusion, and diffusion ultimately leading to respiratory failure.

Capillaries are bypassed and blood is shunted in the oxygenated form from the arteriolar to the venular side, impairing oxygen delivery to the tissues.

Sepsis and greater risk of poor outcome.

Oxygen at high concentration through a face mask.

Hypovolemic shock.

Allergic reaction to antibiotics, especially penicillin, anaesthetics, sera, and dextran, leading to massive vasodilatation and increasing capillary permeability.

In cardiogenic and obstructive shock, neck veins are congested and CVP is high. In neurogenic shock, the pulse is not rapid, and the patient may even have bradycardia.

Pulse, blood pressure, state of filling of veins and capillary perfusion.

5 - 10 cm of water.

It leads to microcirculatory changes, including constriction of precapillary sphincters, sluggish capillary circulation, hypoxia, sludging of blood, and disseminated intravascular coagulation (DIC).

Changes similar to those described under hypovolaemic shock lead to renal failure.

Significant tachycardia (HR >140 bpm), respiratory failure, severe hypotension, anuria, coma.

Maldistribution of cardiac output due to vasodilatation of the arteries and opening of arteriovenous shunts under the effect of cytokines.

Impedance of blood flow to, through or out of the heart due to conditions like tension pneumothorax, cardiac tamponade, or massive pulmonary embolism.

Packed RBCs, plasma, and platelets in 1:1:1 ratio.

If the patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mmHg.

It results from damage to the sympathetic pathways in the cervical/upper thoracic spinal cord, causing massive vasodilatation and inadequate venous return.

Complete vascular collapse with hypotension unresponsive to volume or drug intervention eventually leading to multiple organ failure (MOF) and lethal central nervous system and cardiac dysfunction.

Similar to hypovolaemic shock.

Acute myocardial infarction, cardiac dysrhythmias, myocarditis, valvular heart disease, blunt myocardial injury, cardiomyopathy.

The body aims to stop the bleeding and divert blood from less critical tissues to critical organs like the brain and heart.

The body tries to maintain tissue perfusion to vital organs, activation of sympathetic nervous system and renin-angiotensin-aldosterone system, and blood is shifted to more vital organs.

Failing compensatory mechanisms, worsening tissue damage, and progression to multiple organ dysfunction.

It reduces lung compliance and its expansion.

It is affected.

ECG, cardiac enzymes, Echocardiogram, CXR, CBC, coagulation studies.

Cholestasis and hyperbilirubinaemia may develop, known as 'ICU jaundice'.

Between 1000 and 2000 ml in 45 minutes.

It decreases systemic vascular resistance (SVR) and blood return to the heart.

Colloid solutions such as human plasma, albumin solution, dextran, and artificial blood substitutes.

Accumulation of fluids in the pericardial sac preventing diastolic filling and reducing cardiac output.

ABCs (Remember cervical spine precautions), the patient should lie flat, elevation of the legs, fluid resuscitation with IV crystalloid solution, and use of vasopressors if crystalloid is insufficient.

By clinical manifestations; labs have no role.

A life-threatening organ dysfunction caused by dysregulated host response to infection.

Death.

Rupture of lysosomal and plasma membranes, and cell death.

Defective ventilation, defective perfusion, and defective diffusion.

The brain has auto-regulatory mechanisms that maintain blood flow if the blood pressure drops mildly.

Compensatory mechanisms are overwhelmed with resultant cerebral ischaemia.

Low pH (lactic acidosis), low PO2, low PCO2, and low HCO3.

Balanced salt solution such as Ringer's Lactate.

Restlessness, confusion, fever above 38°C, chills, mild reduction in blood pressure, tachypnoea, tachycardia, flushed warm dry extremities, and oliguria.

Coronary revascularization, positive inotropes (dobutamine), vasopressors (norepinephrine or dopamine).

Measure lactate level. Remeasure if initial lactate is > 2 mmol/L.

Greater than 30ml/hr.

Mal-distribution of blood flow, including neurogenic shock, anaphylactic shock, and septic shock.

Hearing bad news, watching an unpleasant event, or following severe painful stimuli.

Fever, flushed warm skin, confusion, hyperventilation, and tachycardia.

Marked reduction of blood volume. The best indicator of tissue perfusion is urine output.

Can be difficult to recognize, low tissue perfusion leading to cellular hypoxia and lactic acidosis, activation of sympathetic nervous system and renin-angiotensin-aldosterone system.

Vascular endothelial damage caused by cytokines.

Leakage of protein-rich fluid from the circulation into the interstitial space causing edema.

Congested neck veins and a high CVP.

Gastro-duodenal stress ulceration and gut barrier failure.

Blood vessel tone (diameter).

Septic shock.

Greater than 65 mmHg.

Loss of sympathetic outflow and consequent vasodilatation.

They have warm flushed skin due to peripheral vasodilatation.

Peritonitis and infected venous catheter.

It reflects the knowledge of the sequence of events and prevents further reduction in blood volume.

Activation of platelets, neutrophils, and macrophages leading to the release of oxygen free radicals.

When the condition fails to improve despite adequate volume replacement and oxygenation.

Maldistribution of blood, late pump (heart) failure, and hypovolemia.

Oxygen uptake by the cells is impaired.

The amount of blood ejected by the heart in 1 minute.

Stop volume loss.

Elevating diastolic blood pressure and reducing myocardial work.

If blood loss has been severe or haemorrhage is continuing.

Either decrease oxygen delivery to tissues or increase oxygen demand or both.

Airway, Breathing, Circulation.

Obstructive shock.

Peripheral pooling of blood.

Support respiration, circulation, kidneys; fight infection; monitor response.

Ischaemic hepatic dysfunction.

Blood volume is estimated as 70 ml/Kg in adults and 80 ml/Kg in children.

Shock is a state of inadequate tissue perfusion with oxygenated blood that results in cellular dysfunction & damage and organ dysfunction & damage.

Heart, blood, and blood vessels.

Bacterial endotoxin, which is the lipopolysaccharide part of the cell wall of Gram-negative bacilli.

Auto-regulatory mechanisms fail, leading to multiple organ failure (MOF) proceeding faster than in hypovolemic shock.

Percutaneous transluminal coronary angioplasty (PTCA) or fibrinolysis.

Low cardiac output and high jugular venous pressure and CVP.

Begin rapid administration of 30 ml/Kg crystalloid for hypotension or lactate ≥ 4 mmol/L.

Distended neck veins, distant (muffled heart sounds) hypotension, and enlarged cardiac size on chest X-ray.

Cellular demand exceeds production of energy, leading to cellular deterioration and failure of sodium/potassium pump.

Under the effect of catecholamines, the precapillary sphincters constrict, leading to sluggish capillary circulation and hypoxia.

Gram-negative bacilli, staphylococci, and candida.

Peritonitis, cholangitis, genitourinary infections, and infected central venous catheter.

It ends in acute tubular necrosis (ATN) which is a part of the multiple organ system failure.

To achieve a CVP of 10 - 12 cm H20, or a pulmonary wedge pressure of 12 - 15mm Hg, and to improve acidosis, decrease lactate level, and improve urine output.

Systolic blood pressure <90 mmHg, tachycardia, tachypnoea, cold clammy skin, oliguria, and multiple organ failure.

Massive pulmonary embolism, tension pneumothorax, and cardiac tamponade.

When there is evidence of respiratory failure.

Cardiogenic shock.

Acute spinal cord injury, paradoxical bradycardia.